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Prediction of Diabetic Foot Ulcer Occurrence Using Commonly Available Clinical Information - The Seattle Diabetic Foot Study Diabetes Care 29:1202-1207, 2006
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OBJECTIVE—The ability of readily available clinical information to predict the occurrence of diabetic foot ulcer has not been extensively studied. We conducted a prospective study of the individual and combined effects of commonly available clinical information in the prediction of diabetic foot ulcer occurrence.
RESEARCH DESIGN AND METHODS—We followed 1,285 diabetic veterans without foot ulcer for this outcome with annual clinical evaluations and quarterly mailed questionnaires to identify foot problems. At baseline we assessed age; race; weight; current smoking; diabetes duration and treatment; HbA1c (A1C); visual acuity; history of laser photocoagulation treatment, foot ulcer, and amputation; foot shape; claudication; foot insensitivity to the 10-g monofilament; foot callus; pedal edema; hallux limitus; tinea pedis; and onychomycosis. Cox proportional hazards modeling was used with backwards stepwise elimination to develop a prediction model for the first foot ulcer occurrence after the baseline examination.
RESULTS—At baseline, subjects were 62.4 years of age on average and 98% male. Mean follow-up duration was 3.38 years, during which time 216 foot ulcers occurred, for an incidence of 5.0/100 person-years. Significant predictors (P 0.05) of foot ulcer in the final model (hazard ratio, 95% CI) included A1C (1.10, 1.06–1.15), impaired vision (1.48, 1.00–2.18), prior foot ulcer (2.18, 1.61–2.95), prior amputation (2.57, 1.60–4.12), monofilament insensitivity (2.03, 1.50–2.76), tinea pedis (0.73, 0.54–0.98), and onychomycosis (1.58, 1.16–2.16). Area under the receiver operating characteristic curve was 0.81 at 1 year and 0.76 at 5 years.
CONCLUSIONS—Readily available clinical information has substantial predictive power for the development of diabetic foot ulcer and may help in accurately targeting persons at high risk of this outcome for preventive interventions.
OBJECTIVE—To prospectively determine risk factors for foot infection in a cohort of people with diabetes.
RESEARCH DESIGN AND METHODS—We evaluated then followed 1,666 consecutive diabetic patients enrolled in a managed care–based outpatient clinic in a 2-year longitudinal outcomes study. At enrollment, patients underwent a standardized general medical examination and detailed foot assessment and were educated about proper foot care. They were then rescreened at scheduled intervals and also seen promptly if they developed any foot problem.
RESULTS—During the evaluation period, 151 (9.1%) patients developed 199 foot infections, all but one involving a wound or penetrating injury. Most patients had infections involving only the soft tissue, but 19.9% had bone culture–proven osteomyelitis. For those who developed a foot infection, compared with those who did not, the risk of hospitalization was 55.7 times greater (95% CI 30.3–102.2; P < 0.001) and the risk of amputation was 154.5 times greater (58.5–468.5; P < 0.001). Foot wounds preceded all but one infection. Significant (P < 0.05) independent risk factors for foot infection from a multivariate analysis included wounds that penetrated to bone (odds ratio 6.7), wounds with a duration >30 days (4.7), recurrent wounds (2.4), wounds with a traumatic etiology (2.4), and presence of peripheral vascular disease (1.9).
CONCLUSIONS—Foot infections occur relatively frequently in individuals with diabetes, almost always follow trauma, and dramatically increase the risk of hospitalization and amputation. Efforts to prevent infections should be targeted at people with traumatic foot wounds, especially those that are chronic, deep, recurrent, or associated with peripheral vascular disease.
The second abstract above, has this press release associated with it: Landmark Study On Diabetic Foot Infection Published - Renowned Researchers At 3 Universities Unveil Startling Data About Infection-induced Amputation
02 Jun 2006 - 14:00pm (PDT)
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Persons with diabetes who develop an infection are at a 55-fold greater risk for hospitalization, and an alarming 154-fold greater risk for amputation. These are some of the startling figures emanating from the first population-based study on diabetic foot infection. Researchers from Texas A&M University, Rosalind Franklin University of Medicine and Science, and the University of Washington collected data on nearly 1,700 patients over a two-year period.
"The results strongly suggested that foot infections are common and complex. They are also costly in terms of morbidity," noted Dr. Lawrence A. Lavery of Texas A&M, the lead author on the study.
The study also found that nearly 9 in 10 amputations performed are instigated by an infection. "This was perhaps the most interesting figure in the study," noted David G. Armstrong, DPM, PhD, Professor of Surgery and Director of Scholl's Center for Lower Extremity Ambulatory Research at Rosalind Franklin University and one of the study's principal investigators.
"It is infection that is the spark that led to nearly all amputations in this study," said Armstrong. "Poor circulation, while critically important, did not necessarily cause amputation. It determined the level of amputation. This subtlety makes a significant difference when designing strategies for prevention."
The study is published in the June issue of the journal Diabetes Care.
CONTEXT AND OBJECTIVE: Diabetic patients present high risk of having to undergo minor or major amputation during their lifetimes, because of ischemia or infection. The aim of this study was to identify and quantify risk factors for major amputation in diabetic patients with foot infections.
DESIGN AND SETTING: Retrospective clinical-surgical trial at the Vascular Surgery Service of Santa Casa de São Paulo.
METHODS: Ninety-nine patients with diabetic foot infections who underwent 129 hospitalizations in the Vascular Surgery Unit were analyzed in accordance with a pre-established protocol to compare two groups of diabetic patients: one that underwent major amputations and the other that underwent minor amputations or debridements. The patients were predominantly male, in their sixth decade of life, and had type 2 diabetes mellitus. Chronic arterial insufficiency, age, diabetes mellitus duration, ascending lymphangitis, calcaneal lesions, Wagner's classification, laboratory tests and different microorganisms in deep tissue cultures were the risk factors evaluated in all patients.
RESULTS: The statistically significant risk factors for major amputation included age, ascending lymphangitis (odds ratio, OR: 2.5), calcaneal lesions (OR: 10.5), Wagner grade 5 lesions (OR: 3.4), chronic arterial insufficiency without possibility of revascularization (OR: 5.4) and diabetes duration. Presence of Gram-positive microorganisms was associated with the need of major amputation. The serum urea, creatinine, glucose and white blood cell levels were not significant risk factors for major amputation.
CONCLUSIONS: The risk factors for major amputation were: age, ascending lymphangitis, calcaneal lesions, Wagner grade 5 lesions, arterial insufficiency, diabetes duration and Gram-positive microorganisms in cultures.
Re: Predictors of diabetic foot ulcers & infections
Risk factors and healing impact of multidrug-resistant bacteria in diabetic foot ulcers.
Richard JL, Sotto A, Jourdan N, Combescure C, Vannereau D, Rodier M, Lavigne JP; on behalf of the Nîmes University Hospital Working Group on the Diabetic Foot (GP30). Diabetes Metab. 2008 Jul 14. [Epub ahead of print]
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AIM: To determine the risk factors for acquiring multidrug-resistant organisms (MDRO) and their impact on outcome in infected diabetic foot ulcers.
METHODS: Patients hospitalized in our diabetic foot unit for an episode of infected foot ulcer were prospectively included. Diagnosis of infection was based on clinical findings using the International Working Group on the Diabetic Foot-Infectious Diseases Society of America (IWGDF-ISDA) system, and wound specimens were obtained for bacterial cultures. Each patient was followed-up for 1 year. Univariate analysis was performed to compare infected ulcers according to the presence or absence of MDRO; logistic regression was used to identify explanatory variables for MDRO presence. Factors related to healing time were evaluated by univariate and multivariate survival analyses.
RESULTS: MDRO were isolated in 45 (23.9%) of the 188 patients studied. Deep and recurrent ulcer, previous hospitalization, HbA(1c) level, nephropathy and retinopathy were significantly associated with MDRO-infected ulceration. By multivariate analysis, previous hospitalization (OR=99.6, 95% CI=[19.9-499.0]) and proliferative retinopathy (OR=7.4, 95% CI=[1.6-33.7]) significantly increased the risk of MDRO infection. Superficial ulcers were associated with a significant decrease in healing time, whereas neuroischaemic ulcer, proliferative retinopathy and high HbA(1c) level were associated with an increased healing time. In the multivariate analysis, presence of MDRO had no significant influence on healing time.
CONCLUSION: MDRO are pathogens frequently isolated from diabetic foot infection in our foot clinic. Nevertheless, their presence appears to have no significant impact on healing time if early aggressive treatment, as in the present study, is given, including empirical broad-spectrum antibiotic treatment, later adjusted according to microbiological findings.
Re: Predictors of diabetic foot ulcers & infections
Foot ulcer risk and location in relation to prospective clinical assessment of foot shape and mobility among persons with diabetes.
Cowley MS, Boyko EJ, Shofer JB, Ahroni JH, Ledoux WR. Diabetes Res Clin Pract. 2008 Sep 29. [Epub ahead of print]
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AIMS: We assessed baseline clinical foot shape for 2939 feet of diabetic subjects who were monitored prospectively for foot ulceration.
METHODS: Assessments included hammer/claw toes, hallux valgus, hallux limitus, prominent metatarsal heads, bony prominences, Charcot deformity, plantar callus, foot type, muscle atrophy, ankle and hallux mobility, and neuropathy. Risk factors were linked to ulcer occurrence and location via a Cox proportional hazards model.
RESULTS: Hammer/claw toes (hazard ratio [HR] (95% confidence interval [CI])=1.43 (1.06, 1.94) p=0.02), marked hammer/claw toes (HR=1.77 (1.18, 2.66) p=0.006), bony prominences (HR=1.38 (1.02, 1.88), p=0.04), and foot type (Charcot or drop foot vs. neutrally aligned) (HR=2.34 (1.33, 4.10), p=0.003) were significant risk factors for ulceration adjusting for age, body mass index, insulin medication, ulcer history and amputation history. With adjustment for neuropathy only hammer/claw toes (HR=1.40 (1.03, 1.90), p=0.03) and foot type (HR=1.76 (1.04, 3.04), p=0.05) were significantly related to ulceration. However, there was no relationship between ulcer location and foot deformity.
CONCLUSIONS: Certain foot deformities were predictive of ulceration, although there was no relationship between clinical foot deformity and ulcer location.
AIMS: The current study aims to identify risk factors for diabetic foot ulcer and their impact on the outcome of the disease.
METHODS: Three hundred diabetic patients were enrolled in the study. One hundred eighty subjects with diabetic foot ulcer and 120 diabetic controls without foot lesions. All expected risk factors were studied in all patients and after a follow up period, patients with diabetic foot ulcer were classified into group A (patients with healed ulcers) and group B (patients with persistent ulcer or ended by amputation). The risk factors were reanalyzed in both groups to find out their impact on the outcome of the disease.
RESULTS: The following variables were significant factors for foot ulceration: Male gender (P=0.009), previous foot ulcer (P=0.003), peripheral vascular disease (P=0.004), and peripheral neuropathy (P=0.006). Also lack of frequent foot self-examination was independently related to foot ulcer risk. The outcome was related to longer diabetes duration (P=0.004), poor glycaemic control (P=0.006) and anaemia (P=0.003) and presence of infection (P<0.001).
CONCLUSIONS: Peripheral vascular disease and peripheral neuropathy together with lack of foot self-examination, poor glycaemic control and anaemia are main significant risk factors for diabetic foot ulceration.
Re: Predictors of diabetic foot ulcers & infections
Hey, sort of off subject but not, i wondered if anyone know where i could get information(referance-able!!) about pontential ulceration sites of someone with diabetes, I am looking at callus debridement in my literature appraisal and ideally want to make a map of potential areas in which to compare sites to those who do not have ulcers as yet but hard skin. Your expertise would be much appreciated.
Thanks
Hannah
Predictors of diabetic foot ulcers & infections
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